Lip Filler Botox/Dermal Fillers Consent Form Client Name: D.O.B. Address Postcode Mobile number Email Reason for having treatment: Please tick what treatment you are having: Botulinum Toxin (Botox)Dermal FillersOther Health Questionnaire Are you pregnant / breastfeeding? YesNo Have you undergone any medical procedure in the past 4 weeks? YesNo Have you undergone any surgical procedure in the past 6 weeks? YesNo Do you bruise easily? YesNo Do you suffer horn needle Phobia? YesNo Do you have history of / tendency to faint? YesNo Do you have any tendency to keloid of excessive scarring? YesNo Have you ever tested positive for HIV or Hepatitis B / C? YesNo Have you ever been diagnosed of any of the following: Angina, Diabetes, Epilepsy. Hepatitis A, Rheumatoid Arthritis, Thyroid, Auto immune disease YesNo Have you ever been diagnosed of multiple sclerosis (MS), myasthenia gravis or any other neuromuscular degenerative disorder? YesNo Have you been diagnosed with any severe mental condition requiring medication and/or hospital admission? YesNo Have you had abnormal reaction to such procedure before? YesNo Do you have tendency to develop cold sores, or had one in the past 2 weeks YesNo Do you have history of anaphylaxis (severe allergic reaction) YesNo Do you have history Of allergy to any medicines / food / drink YesNo Have you ever had abnormal reaction to local anaesthetic (injection / cream)? YesNo Are you taking HRT, steroids or blood-thinners (anticoagulants, e.g. warfarin)? YesNo Have you taken any antibiotics in the past week?(esp. Gentamicin, Amikacin, Neomycin, Netilmicin(Netromycin) or Tobramycin) YesNo in the area to be treated: Have you received any aesthetic treatment (e.g. fillers) in the past 2 weeks? YesNo Do you suffer from active skin condition: eczema, acne, psoriasis or cancer? YesNo Do you have any permanent implants? YesNo If you answer yes to any of the above questions, please provide further information; Common Side Effects Associated with the injection Pain or stinging sensation when the injectIon is performed Localised swelling, redness and or tenderness Bleeding at the sites of injection Bruing. Rarely bruising may be severe and may persist for several weeks Numbness or itching of the area following injection Common side effects are expected to resolve spontaneously within the first few days of treatment. Whilst not expected, it is possible that reactions described may persist for longer and may inhibit your confidence to attend work or social events. You are advised to schedule treatrnents with this in mind, allowing time for common reactions such as bruising and swelling, to settle. Uncommon Side Effects Infecton Inflammation Skin discolouration (which may occur within a few days or weeks to months following treatment) Allergic or sensitivity reaction, which may be local (redness, itching or rash at the site of treatment) or may be severe requiring hospital treatment Abscess formation A foreign body reaction, known as 'granuloma' presenting as lumps or nodules The blood supply to the skin may be interrupted by swelling or inadvertent injection into a vessel, causing pain, skin damage and possible scarring. Correction is expected to last for a period of 6-12 months. The successful outcome varies by degree and how long it lasts vanries from one individual to another and cannot be guaranteed. I understand if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented and managed in a timely fashion. I confirm that the medical health history form has been completed truthfully and I am fully aware that withholding medical infomtation, including history of previous treatment, may be detrimental to the safe and optimal outcome of any treatment administered. If there are any changes in my medical history, I must inform the practitioner. I confirm that I have been provided with verbal and written information about this treatment which includes aftercare and follow up advice. I agree to follow the aftercare advice and understand this reduces risk of adverse reactions and helps ensure optimum results. I understand informatton about me will be treated as confidential and access to it restricted in accordance with the Data Protection Act, unless specific permissions given. I consent to photographs being taken for my personal record only and will not be published unless specific and further consent from me is granted. I accept no fee is payable to me or any other person in respect of the material either now or at any time in the future. I accept clinic Terns and Conditions I am satisfied the procedure has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan.
